Postmortem procedures: services for the deceased need the same respect as when the person was alive. (Human Resources).

A loved one's impending death is never easy for family members. It's also not a simple matter for caregivers.

A lot of groundwork goes into handling a resident's death, including dealing with the caregiver's own feelings on death and dying, according to caregiver trainer Judith Kiriloff, RN, a consultant to Assisted Living Federation of America (ALFA) University in Fairfax, Va.

"The better the caregiver is prepared, emotionally and intellectually, the more helpful she will be," she says.

The ALFA consultant recommends teaching your staff what to expect when a patient dies. "One aide in a home where I worked witnessed her first death and was very relieved to find that the event was not a frightening one," Kiriloff says.

After departure

A caregiver must know what to do after a resident dies, according to Kiriloff. Certain state guidelines may have to be followed, and of course, all steps have to follow the facility's policy. For instance, who determines that the resident has died? Should the facility call a physician or may a nurse declare the resident dead? Facility rules should also cover who must notify the family.

Postmortem care should take place as soon as possible, although if the caregiver is unlicensed, she or he might have to wait for the nurse to arrive. "Dignity, respect and privacy must be accorded the deceased, the same as for the living," Kiriloff says.

Caregivers should be trained to wash their hands and put on gloves. They should know how to close the resident's eyes, bathe the resident, and put on a clean gown, a bed protector and clean bed sheets. The caregiver will have to position the body properly, remove dentures or put them back in the mouth, gently close the person's mouth, and comb or brush his or her hair.

Normal light should be maintained in the room, as the family might wish to view the body, Kiriloff says.

Caregivers should also keep in mind the deceased's religious convictions. They should ask if the family wants a minister, priest or rabbi. They also need to remember procedural matters. For example, Orthodox Jews may not want the body touched, according to Kiriloff.

The decision of whether to leave the body in the room has to be made in consultation with the roommate, according to Tom Burke, a spokesman at the American Health Care Association in Washington, D.C. If the roommate agrees to leave for a while, the body can rest in the room for the family's visitation. Otherwise, relocation will be necessary.

Speaking to the family is a matter of delicacy. Kiriloff stresses that caregivers must realize that they can't speak as a family member, and should not utter comments such as "It is God's will" or "She/He is better off." The most that the facility representative should say is "I'm sorry for your loss." It's the job of the caregiver or administrator to support the family by reminding people of a pleasant memory about the deceased, Kiriloff says.

Burke adds that the resident's possessions must be dealt with in a sensitive way, not just handed to someone in a paper bag.

"After the death of a resident, the staff should be open and honest with the other residents, although not to the extent of disclosing the details, which are private," Kiriloff states. "Residents will watch to see how you deal with this because they know that you will handle their deaths similarly and they have some anxiety about that."

Burke agrees. "Facilities realize they are dealing with adults, and the staff speaks much more openly."

Hospice can help

More and more, the facility is spared the necessity of dealing directly with the death of a resident through the use of a hospice. A Medicare entitlement, a hospice can relieve the facility of responsibilities even at the point of death and afterward, says Todd A. Picou, the administrator of Hospice Care of South Carolina in Spartanburg, S.C.

"When a hospice patient dies, we are there almost all of the time for the patient's expiration," says Picou, a licensed nursing home administrator. "We clean the body, preparing it for the coroner or morgue."

The hospice will call the family, unless the facility prefers to do so. "Generally, we have kept good track of what is going on with that individual resident and are there with the family," Picou says.

That is the time to allow the family to be alone with the body or to share stories and express their feelings, Picou says. He also recommends that staff be permitted to pay their last respects. "A lot of times, they are the family members who get left out."

Hospice Care of South Carolina bows to the rules set down by the facility. Still, the hospice staff will gladly take over from the residence, with the hospice nurse pronouncing the death, and the hospice handling all notifications, Picou says.

In an assisted living situation, because there is no hands-on nursing care, the hospice takes on a larger role--especially if the facility has no policies in place. But even there, Picou's hospice workers have been told to cede to the wishes of the assisted living management.

According to Picou, information regarding the hospice should be handed to residents' families during the admission process. From there, Hospice follows up with families by sending cards, calling and even visiting. Hospice personnel can refer families to community support groups, educational opportunities and counseling, Picou says.

Funeral direction

Usually, the family takes cares of funeral arrangements during admission. But it still doesn't hurt for operators of long term care facilities to form relationships with local funeral directors. Such relationships can provide the facilities with some of its best guidance.

"I [often] get calls from someone at a nursing home at 3 a.m., alerting me to a person's death, but telling me, 'Don't come now, come later. The family is on its way.' That's not the right way to handle this," cautions funeral director David Walkinshaw, a third-generation owner and operator of Saville and Grannan, a funeral home in Arlington, Mass. "We are not going to put our men outside in a car at 4 a.m. to wait."

Walkinshaw's most ardent suggestion is that newly built facilities be designed with a room near an exit where the deceased can be taken until the funeral director arrives. "We feel very badly for the residents who have to watch men in black suits carry a stretcher through the halls," Walkinshaw says. "It's awkward."

Retrieving the deceased can be especially uncomfortable in the older and less-affluent homes, in which five, six or seven people share a single room. Walkinshaw recalls being in a facility one night and having someone point to a darkened room for him to take away the body. "This caregiver was probably good to the resident when she was alive, but now she didn't want to go in the room," says Walkinshaw. "Try to figure out who is the deceased in a dark room in which several elderly people are asleep."

To protect everyone's feelings as well as the dignity of the person who has died, Walkinshaw says the nurse or aide should go into the room with the funeral director and show him the deceased.

Preparations made perfect

So how should funeral preparations be done? Ronald Troyer, manager of the Kok Funeral Home in St. Paul Park, Minn., asks facilities to prepare the deceased's vital statistic for the death certificate and to specify the doctor and his or her phone number, so Troyer may easily obtain the required signature.

Troyer would like some lead time to organize the pick-up and asks that the facility inform him that the death has occurred. A 3 a.m. call, of course, will wake someone up, so good judgment is advised. If the family is present, however, Troyer would like to get there in time to speak to them.

He also understands the sentiment of everyone who regularly deals with these situations: The staff is often left out of the grieving process, even though they might have been extremely close to the deceased. So Troyer doesn't mind if an aide assists or is present at the removal. Aides often come to a visitation or attend the funeral, he says.

Troyer will also bring the casket to the long term care center and go to the cemetery from there, if there is a desire for that. This presents an opportunity for residents to attend who wouldn't otherwise be able to, he says.

Inviting a funeral director to give in-house service training is an ideal way to acquaint new aides with how a death should be handled, and Troyer, who was on the board of a long term care facility for nine years, has presented many of these sessions. "This facilitates communication between the funeral home and the nursing home and has very positive outcomes," he says.

John Horan, an owner of Horan & McConaty Funeral Service/Cremation in Denver, invites the facility to communicate aspects of the person that were special. "When I go into the resident's room and see photos and mementos, I ask if any of this is significant and should be represented at the service," says Horan. He suggested at a recent funeral that a quilt the deceased had made be placed at the foot of the casket, a touch that the family found meaningful.

"The nurse's aides know the intimate details of that person's life and often provide information that makes a funeral service unique and memorable," he says.

Horan appreciates knowing in advance if there will be size or weight difficulties with the removal because he often comes alone with an adjustable cot. If there are special logistics, he will bring one or two more people.

If the family is there when Horan arrives, he enters the room without his gurney and speaks to them. "I tell them what is going to happen and answer the family's immediate questions. Then I ask if this is a good time to transfer their mother," he comments. "The nurses are quite good at telling me when the time is right, too."

The facility staff members who prepare the body should leave on any diaper and use good judgment in whether to remove an IV. If taking it out will present an opportunity for body fluids to leak, the IV should be left in, Horan says. The funeral home will dispose of this appropriately with other medical waste.

After the caregiver cleans the body, he or she can close the deceased's eyes and move a towel behind the neck and one under the chin to hold the jaw closed. "The staff ought to prepare the family for what they will see when they go in the room," advises Horan. The nurse or aide should go in first to check and perhaps close the person's eyes a second time, so they won't be open when the family enters.

The aide should also check again to see that the bed linen is not soiled and be sure the covers are pulled over the towel at the neck, he counsels. "The aide can explain to the family, 'I've just rolled up a towel so her mouth is closed,' " Horan says.

Once he is actually out of the building, Horan says he covers the face.

Feedback from the facility is important to Horan. He wants to know when someone has done their job well, or if they have behaved without respect.

RELATED ARTICLE: An End-of-Life Question: Where to Go?

As a resident approaches the end of his or her life, it's often not just a matter of preparing for that resident's death. It's also an issue of where that patient may receive his or her last months of care.

It's true that many assisted living facilities would have required terminally ill residents to leave for nursing homes a few years ago. Now, with the new general availability of hospices, these individuals can remain in place, says Judith Kiriloff, one of the authors featured in "Providing End-of-Life Care in Assisted Living," published by the Assisted Living Federation of America (ALFA) University (800/258-7030) in Fairfax, Va.

But still, not everyone can stay in the same home until death, according to Kiriloff. "As the person's acuity level rises, the family must be able to afford any needed around-the-clock care. Otherwise, the resident will have to be sent to another facility," Kiriloff says.

Constant care is not provided under hospice, she says. In addition, not all facilities have the training or the means to watch over someone who needs attention at all times.

For assisted living to even undertake retaining a resident with hospice needs is a difficult matter, since a facility caregiver must be taught, and perhaps accredited, to administer medications left by hospice, Kiriloff says.

Should infusion therapies become necessary, only a nurse can administer those therapies, Kiriloff says,

When It's Time to Say 'Good-bye'

Michelle Conrad

In my personal life, I have lost many friends and family. In my work as a certified nurses' assistant, I have seen the various ways death takes the people you care about. If you ever need to be there for someone at the end of their life, these tips will help you be the caregiver that person needs. To do that, you will need a heart, a head, some time and patience. A word of caution: The following may touch your heart and the way you think or the way you hope.

Treat all residents as human beings. Just because someone is ready to leave this life does not mean that he or she should be treated carelessly. I once saw a nurse treat a very sick man who had no control of his movements as if he were a rag doll. She rolled him over with a push, as if he were already dead.

Treat residents with the respect they deserve. Some diseases affect the mind. I've seen some elderly people behave as if they were children, and some axe offended by pet names such as "honey," "sweetie," "baby" and "dear." Most older folks prefer Mr., Mrs. or just their first names. I once took care of a man who was a captain in the military and wanted to be called "Captain."

Try to be patient. Death comes when it is ready, not when you are. You may hope this person passes on quickly so he or she doesn't suffer anymore. But, it doesn't always work that way. I became very attached to a lady who was a diabetic and legally blind. She used to call me Gabriel. I was her angel here, she told me, and she would be mine when she had gone to Heaven. On her last day, I stayed with her as long as I could. During that time, a co-worker came to me for help. So, I had a good friend sit with my "angel." My friend came to me about 30 seconds later and told me that after I had left the room, my "angel" had taken her last breath. I think she waited for me to leave so she could.

Don't wait until it is too late. Come and visit while you can. Say all the things you want to say or need to say before that person is gone. My younger sister and I had been disagreeing about some things when my grandmother told us to stop acting like children. "Kiss and make up," she said. "Tell each other 'I love you.' You never know if one of you won't be here tomorrow!" The day after I told my little sister that I loved her no matter what, I received a phone call telling me she had been killed in a car accident.

Don't be afraid to touch. Hug someone who needs one, even if you are the one who needs to be held the most. Sit down in a chair and hold hands, or sit on their bed if they will allow it.

Don't be afraid to get close. When I went to check on a resident one day, I was surprised at first to see his wife sitting in bed with him. This man could not move himself around and he was hooked up to many machines, His wife could not have weighed more than 90 pounds and he weighed approximately 150. She had gotten into bed behind him and sat cross-legged so she could pull him into her arms to rock. After making sure she didn't need anything, I left the room.

Do something to help. Ask if you can bring something, a favorite book, a pillow or maybe a picture. Even a favorite food, if it's okay. These people are sometimes just afraid. They want to know what is going to happen to them. How will it be at the end? Will I look different? I have had numerous conversations with residents who just wanted someone to listen to their fears and hold them while they cry. I don't know the answers to their questions, but I always listen. Sometimes that's all you can do.

Accept their feelings about death. Some people just cannot be around death in any way. I remember one gentleman's son who, when we called to say that he should come to say goodbye, he told us to just make his dad as comfortable as we could. We all took turns sitting with his clad and felt he knew he wasn't alone. Others just don't know how or don't want to say goodbye. Some residents also wish for no one to be there when they go. I respect that wish. Everyone should be allowed to die the way they want to.

My job is about helping people when they need it the most, being there when they need to be cared for and cared about. I have seen many people come to the end of their lives, each a little differently but somehow all the same. This is when I feel that I can do my best for them. I open the window a little bit to let their souls soar up to the sky. While I wash them, I usually say a little prayer of thanks for the chance to be a part of their lives. Death used to be hard for me to accept and understand. I've learned what it is and what it isn't. It can be the most peaceful thing in the world you have ever experienced, almost magical with the transformations the body makes.

My thought is this: If you have the chance to be there for someone who needs you before they leave this world, go. Talk to them, touch them, tell them you love them and sit with them while they go to a better place--if you can.

Michelle Conrad, CNA, currently works full-time at Seaside Rehabilitation and Nursing Center in Portland, Maine. She is also a part-time student at Southern Maine Technical College in South Portland, Maine, working toward her RN degree, and is a mother of two.

Gail Hayden is a New York-based freelance writer who covers the long term care industry.